The Care Coordination in the Community project, is supported by the CCTST Community Leaders Institute and led by Dr. Ernie Ciambarella (Queen City Physicians). The project involves five community based practices that are working together to develop sustainable and reliable processes for care coordination between the medical home and specialists at Cincinnati Children’s. Dr. Ciambarella convened a series of meetings with parents of children with medical complexity and practice team members to gather their insights to ensure the processes being developed met their needs. Tests of change have included using the Longitudinal Plan of Care (LPOC) in EPIC to support pre-visit planning and care coordination. The initial experience showed that the LPOC made the process more efficient for physicians, office staff, and parents. However, this test also raised awareness that the LPOC needs to be available in EPIC Link (in addition to EPIC) so non-physician staff members at community practices can access it. Leadership at Cincinnati Children's responded to this need by enhancing EPIC Link.
We produced a short video to share learnings from this project. Click here to watch “Practical Tips about Pre-Visit Planning for Children with Medical Complexity.”
The sample care management plan featured in the video is available for download.
Community practices that refer patients to Cincinnati Children’s who would like to establish access to Epic Link can contact Stefanie Easley in Physician Services for additional information. Phone: 636-6033 or Email: firstname.lastname@example.org